1203
An Update on Cancer in American Indians and Alaska
Natives, 1999–2004
Supplement to Cancer
Prostate Cancer Incidence Among American Indian
and Alaska Native Men, US, 1999–2004
Jeffrey A. Henderson, MD, MPH1
David K. Espey, MD2
Melissa A. Jim, MPH2
Robert R. German, DrPH, MPH2
Kate M. Shaw, MS2
Richard M. Hoffman, MD, MPH3
BACKGROUND. American Indian and Alaska Native (AI/AN) men experience lower
incidence of prostate cancer than other race/ethnic populations in the US, but
racial misclassification of AI/AN men threatens the validity of these estimates. To
the authors’ knowledge, little is known concerning prostate-specific antigen (PSA)
testing in AI/AN men.
METHODS. The authors linked cancer registry data with Indian Health Service
enrollment records to improve race classification. Analyses comparing cancer
1
Black Hills Center for American Indian Health,
Rapid City, South Dakota.
2
Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta,
Georgia.
3
University of New Mexico Cancer Center, Albuquerque, New Mexico.
incidence rates and stage at diagnosis for AI/AN and non-Hispanic white (NHW)
men for 6 geographic regions focused on counties known to have less race misclassification. The authors also used Behavioral Risk Factors Surveillance System
data to characterize PSA testing in AI/AN men.
RESULTS. Prostate cancer incidence rates were generally lower in AI/AN than in
NHW men for all regions combined (rate ratio of 0.68). However, regional variation
was noted among AI/AN men, with incidence rates (per 100,000 population) ranging
from 65.7 in the Southwest to 174.5 on the Northern Plains. The rate of distant stage
disease was somewhat higher among AI/AN (7.8) than NHW (6.2) men. Nationally,
AI/AN men were less likely than NHW men to have undergone recent PSA testing
(48.4% vs 58.0%), with prominent regional variation in screening rates noted.
CONCLUSIONS. Prostate cancer incidence rates and the proportion of men with
recent PSA testing were lower for AI/AN men than for NHW men. However, incident rates and rate of distant stage varied by region more for AI/AN than for
This supplement was sponsored by Cooperative
Agreement Number U50 DP424071-04 from the
Centers for Disease Control and Prevention, Division of Cancer Prevention and Control.
The findings and conclusions in this report are
those of the authors and do not necessarily
represent the official position of the Centers for
Disease Control and Prevention.
Address for reprints: Jeffrey Henderson, MD,
MPH, Black Hills Center for American Indian
Health, 701 St. Joseph Street, Suite 204, Rapid
City, SD 57701; Fax (605) 348-6990; E-mail:
[email protected]
*This article is a US Government work and, as
such, is in the public domain in the United
States of America.
Received May 5, 2008; accepted June 3, 2008.
NHW. Further research is needed among AI/AN men to evaluate strategies for
better understanding the causes of the regional variation in prostate cancer
incidence. Cancer 2008;113(5 suppl):1203–12. Published 2008 by the American
Cancer Society.*
KEYWORDS: prostate cancer, cancer, incidence, American Indian, Alaska Native,
misclassification, National Program of Cancer Registries (NPCR), Surveillance, Epidemiology, End Results (SEER), US, health disparity.
rostate cancer is an important health issue for men in the US,1
including American Indian/Alaska Native (AI/AN) men.2 It is the
second-leading cause of cancer death for men of all races combined
and for AI/AN men.3 Largely because of race misclassification, the
accuracy of prostate cancer incidence and stage data among AI/AN
men has been uncertain; prior publications on the subject focused
on specific geographic regions4,5 and thus were not generalizable to
other AI/AN populations. Furthermore, the association between can-
P
Published 2008 by the American Cancer Society*
DOI 10.1002/cncr.23739
Published online 20 August 2008 in Wiley InterScience (www.interscience.wiley.com).
1204
CANCER Supplement
September 1, 2008 / Volume 113 / Number 5
cer incidence and prostate-specific antigen (PSA)
testing among AI/AN men has not been well
described.
The purpose of the current study was to better
estimate prostate cancer incidence and stage at diagnosis in AI/AN men, using techniques to minimize
race misclassification. We present these data by geographic region and for all regions combined. We also
described patterns of PSA testing among AI/AN men,
identified the demographic and behavioral factors
associated with testing, and evaluated ecologic associations of PSA testing with prostate cancer incidence.
MATERIALS AND METHODS
Detailed descriptions of the data sources and methods used for this analysis are found elsewhere in this
supplement.6
Cancer Cases
We identified cancer cases using data collected by
the National Program of Cancer Registries of the
Centers for Disease Control and Prevention (CDC)
and the Surveillance, Epidemiology, and End Results
(SEER) Program of the National Cancer Institute
(NCI).7 Registries coded primary cancer site and histology data according to the third edition of the
International Classification of Diseases for Oncology
(ICD-O).8 We used data regarding invasive cancers
(ICD-O-3 C619) to calculate incidence rates. Included
cases are from state registries that agreed to participate in this project and met the US Cancer Statistics
standards for high-quality data.7
We classified race by combining information
from 2 sources: 1) data linkages with Indian Health
Service (IHS) patient registration records and 2) the
multiple race fields in cancer registry records. The
IHS provides medical services to AI/AN persons who
are members, or descendents of members, of federally recognized tribes. To reduce race misclassification, states linked all case records with the IHS
patient registration database to identify AI/AN cases
misclassified as some other racial group. Further
details about coding rules for multiple races are
described elsewhere in this supplement.6
To further improve race classification, we focused
analyses on Contract Health Service Delivery Area
(CHSDA) counties (Fig. 1), which generally contain
federally recognized tribal lands or are adjacent to
tribal lands. The proportions of AI/AN in relation to
total population are higher in CHSDA counties than in
non-CHSDA counties, and data indicate less race misclassification for AI/AN in these counties.9 Approximately 56% of the US AI/AN population resides in
FIGURE 1. State and Contract Health Service Delivery Area (CHSDA) counties used in cancer incidence analyses for the American Indian and Alaska
Native population are shown by Region.
CHSDA counties. This proportion varies by IHS region:
Alaska: 100%; East: 13.1%; Northern Plains: 59.0%;
Southern Plains: 64.1%; Pacific Coast: 55.6%; and
Southwest: 87.5% (in each region, the proportion of
AI/AN in CHSDA counties to AI/AN in all counties.) In
addition, our analyses stratified incidence rates by IHS
regions (Alaska, Pacific Coast, Northern Plains, Southern Plains, Southwest, and East) to evaluate the geographic variation of cancer incidence in the AI/AN
population (Fig. 1). Additional details concerning
CHSDA and IHS are provided elsewhere.6
Stage of disease data spanned changes in SEER
summary stage coding. Stage was coded according to
SEER Summary Stage 1977 rules for diagnosis years
1999 to 2000 and according to SEER summary stage
2000 rules for diagnosis years 2001 to 2003; collaborative stage data, first reported for 2004, were not
available for analysis. We reported stage data for
2001 to 2003 because of significant changes in coding local and regional stage disease between the 2
staging systems.10,11
Population Estimates
The NCI makes further refinements to population estimates produced by the CDC and the Census Bureau
regarding race and county geographic codes; the estimates for the period 1999 to 2004 were used as
denominators for the rate calculations in this report.12
PSA Testing and Demographic, Health, and
Socioeconomic Indicators
We used data from the Behavioral Risk Factor Surveillance System (BRFSS) to characterize PSA testing
in the AI/AN and NHW populations and to evaluate
Prostate Cancer Incidence Among AI/AN Men/Henderson et al
1205
TABLE 1
Prostate Cancer Incidence by Indian Health Service Region for American Indians/Alaska Nativesa and Non-Hispanic Whites, US, 1999-2004
CHSDA Counties
All Counties
IHS Region
AI/AN
Count
AI/AN
Rateb
95% CI for
AI/AN Rate
NHW
Rateb
Rate Ratio
(AI/AN:NHW)
95% CI for
Rate Ratio
AI/AN
Count
AI/AN
Rateb
95% CI for
AI/AN Rate
NHW
Rateb
Rate Ratio
(AI/AN:NHW)
95% CI for
Rate Ratio
Northern Plains
Alaskad
Southern Plains
Pacific Coast
East
Southwest
Total
499
124
834
447
114
457
2475
174.5
78.3
156.7
83.2
83.9
65.7
105.6
157.8-192.4
63.7-95.0
145.7-168.3
74.9-92.0
68.1-102.0
59.5-72.2
101.2-110.1
162.2
180.7
146.5
160.8
155.9
133.8
154.4
1.08
0.43c
1.07
0.52c
0.54c
0.49c
0.68c
0.97-1.19
0.35-0.53
0.99-1.15
0.47-0.57
0.44-0.65
0.44-0.54
0.66-0.71
651
124
930
586
646
492
3429
133.6
78.3
126.6
60.6
63.8
63.6
83.5
122.2-145.7
63.7-95.0
118.1-135.6
55.4-66.2
58.6-69.3
57.8-69.7
80.5-86.6
161.7
180.7
147.8
161.6
149.7
146.9
153.4
0.83c
0.43c
0.86c
0.38c
0.43c
0.43c
0.54c
0.76-0.90
0.35-0.53
0.80-0.92
0.34-0.41
0.39-0.46
0.39-0.47
0.52-0.56
IHS indicates Indian Health Service; CHSDA, Contract Health Service Delivery Areas; AI/AN, American Indian/Alaska Native; 95% CI, 95% confidence interval; NHW, non-Hispanic white.
a
AI/AN race is reported by National Program of Cancer Registries and Surveillance, Epidemiology, and End Results registries or through linkage with the IHS patient registration database. AI/AN persons of Hispanic origin are included.
b
Rates are per 100,000 persons and are age-adjusted to the 2000 US standard population (19 age groups, Census P25-1130).
c
Rate ratio is statistically significant (P<.05).
d
Rates and rate ratios for Alaska in the CHSDA Counties section is the same as those in the All Counties section because all counties in Alaska are CHSDA counties.
Years of data and registries used: 1999 to 2004 (41 states and DC; *indicates states with at least 1 county designated as CHSDA): Alaska,* Alabama,* Arkansas, Arizona,* California,* Colorado,* Connecticut,* District of Columbia, Delaware, Florida,* Georgia, Hawaii, Iowa,* Idaho,* Illinois, Indiana,* Kentucky, Louisiana,* Massachusetts,* Maine,* Michigan,* Minnesota,* Missouri, Montana,* North Carolina,* Nebraska,*
New Hampshire, New Jersey, New Mexico,* Nevada,* New York,* Ohio, Oklahoma,* Oregon,* Pennsylvania,* Rhode Island,* Texas,* Utah,* Washington,* Wisconsin,* West Virginia, and Wyoming*; 1999 and 2002
to 2004: North Dakota*; 2001 to 2004: South Dakota*; 2003 to 2004: Mississippi* and Virginia; 2004: Tennessee.
Percent regional coverage of AI/AN in CHSDA counties to AI/AN in all counties: Alaska: 100%; East: 13.1%; Northern Plains: 59.0%; Southern Plains: 64.1%; Pacific Coast: 55.6%; Southwest: 87.5%.
the influence of demographic, health, and socioeconomic factors on PSA testing. BRFSS is a cross-sectional telephone survey conducted by all state health
departments and the District of Columbia. PSA testing questions were part of the BRFSS core module in
2001, 2002, 2004, and 2006. Respondents were asked
if they had ever had a PSA test and the time since
their last test. BRFSS data presented here include
data from all counties of the 50 states and the
District of Columbia (ie, are not limited to CHSDA
counties). More detailed methodology regarding the
BRFSS has been published in this supplement and
elsewhere.13,14
Statistical Analyses
Two sets of basic descriptive statistics are provided
for AI/AN and NHW men: 1) data from CHSDA
counties in all states that meet quality criteria and 2)
data from all counties in all states that meet cancer
registry data quality criteria (referred to as ‘All Counties’). In addition, CHSDA and All Counties data are
provided for each IHS region. The results described
in the text refer to persons who resided in CHSDA
counties, unless otherwise noted. Additional information regarding cases and population coverage is
available elsewhere in this supplement.6
For AI/AN and NHW populations, prostate cancer
incidence rates are expressed per 100,000 and ageadjusted to the 2000 US standard population using 19
age groups (Census P25-1130). In addition, we per-
formed a stratified analysis by 4 age groups (<50, 50-64,
65-74, and 75 1 years) based on screening recommendations,15 and the provision of Medicare benefits for
those aged 65 years. Age-group specific rates are also
age-adjusted within each age category. Stage-specific
rates and percent distributions of stage of disease at diagnosis are also age-adjusted. Age-adjusted rates were
generated using SEER*Stat Software (version 6.3.6).16
For all analyses, exact counts were suppressed when the
category of interest contained 5 or fewer cases.
Using the age-adjusted incidence rates, standardized rate ratios (RRs) were calculated for AI/AN
men using NHW rates for comparison. Confidence
intervals (CIs) for age-adjusted rates and standardized RRs were calculated based on methods
described by Tiwari et al17 using SEER*Stat 6.3.6.16
We report the proportions and 95% CIs for PSA
testing within the last year for all male AI/AN and
NHW BRFSS respondents aged 50 to 75 years, overall
and stratified by region. We also report the proportions and 95% CIs of those with recent PSA testing
by key demographic, socioeconomic, and health
behavior factors. The BRFSS data presented herein
are not restricted to CHSDA counties.
RESULTS
In CHSDA and All Counties, the prostate cancer incidence rate for all regions combined for AI/AN men
was lower than the rate for NHW men (Table 1). The
1206
CANCER Supplement
September 1, 2008 / Volume 113 / Number 5
TABLE 2
Prostate Cancer Invasive Incidence Ratesa and Rate Ratiosb by Age and Indian Health Service Region for American Indians/Alaska Nativesc and
Non-Hispanic Whites, CHSDA Counties, US, 1999 to 2004
<50 Years
IHS Region
CHSDA counties
Northern Plains
Alaska
Southern Plains
Pacific Coast
East
Southwest
Total CHSDA
50-64 Years
65-74 Years
751 Years
AI/AN
Ratea
NHW
Ratea
RRb
95% CI
AI/AN
Ratea
NHW
Ratea
RRb
95% CI
AI/AN
Ratea
NHW
Ratea
RRb
95% CI
AI/AN
Ratea
NHW
Ratea
RRb
95% CI
5.1
2.0
2.3
1.6
2.9
0.9
2.1
4.3
4.6
3.6
4.2
4.6
4.0
4.2
1.19
0.43
0.63
0.39c
0.64
0.24c
0.51c
0.73-1.81
0.11-1.11
0.33-1.08
0.20-0.67
0.21-1.46
0.10-0.46
0.39-0.65
257.6
162.1
237.6
133.8
172.5
92.8
165.2
303.4
313.7
249.6
305.2
301.5
273.4
295.1
0.85b
0.52b
0.95
0.44c
0.57c
0.34c
0.56c
0.73-0.98
0.39-0.68
0.84-1.08
0.37-0.51
0.43-0.75
0.28-0.40
0.52-0.60
893.7
297.5
879.5
521.4
399.5
358.8
578.1
953.3
1043.1
830.7
929.9
901.9
769.0
892.5
0.94
0.29b
1.06
0.56c
0.44c
0.47c
0.65c
0.80-1.09
0.20-0.40
0.94-1.18
0.48-0.65
0.30-0.62
0.40-0.54
0.61-0.69
1212.6
545.3
1016.7
455.8
489.4
453.8
681.1
839.5
1017.3
854.6
838.7
792.6
648.8
798.6
1.44b
0.54b
1.19b
0.54c
0.62c
0.70c
0.85c
1.19-1.74
0.35-0.80
1.03-1.37
0.43-0.68
0.39-0.92
0.58-0.83
0.79-0.92
Source: Cancer registries in the National Program of Cancer Registries of the Centers for Disease Control and Prevention and/or the Surveillance, Epidemiology, and End Results program of the National Cancer
Institute.
IHS indicates Indian Health Service; CHDSA, Contract Health Service Delivery Areas; AI/AN, American Indian/Alaska Native; NHW, non-Hispanic white; RR, rate ratio.
a
Rates are per 100,000 persons and are age-adjusted to the 2000 US standard population (19 age groups, Census P25-1130).
b
Rate ratios are calculated in SEERaStat prior to rounding of rates and may not equal rate ratios calculated from rates presented in the table.
c
Rate ratio is statistically significant (P<.05).
Years of data and registries used: 1999 to 2004 (41 states and DC; *indicates states with at least 1 county designated as CHSDA): Alaska,* Alabama,* Arkansas, Arizona,* California,* Colorado,* Connecticut,* District of Columbia, Delaware, Florida,* Georgia, Hawaii, Iowa,* Idaho,* Illinois, Indiana,* Kentucky, Louisiana,* Massachusetts,* Maine,* Michigan,* Minnesota,* Missouri, Montana,* North Carolina,* Nebraska,*
New Hampshire, New Jersey, New Mexico,* Nevada,* New York,* Ohio, Oklahoma,* Oregon,* Pennsylvania,* Rhode Island,* Texas,* Utah,* Washington,* Wisconsin,* West Virginia, and Wyoming*; 1999 and 2002
to 2004: North Dakota*; 2001 to 2004: South Dakota*; 2003 to 2004: Mississippi* and Virginia; 2004: Tennessee.
rate of prostate cancer in AI/AN men residing in
CHSDA counties was higher than the AI/AN rate for
All Counties for 5 of 6 regions and for all regions
combined. Little variation was noted between
CHSDA and All Counties for NHW men. AI/AN incidence rates in CHSDA counties varied widely by
region and ranged from 65.7 (per 100,000 males) in
the Southwest to 174.5 in the Northern Plains,
whereas NHW rates ranged from 133.8 in the Southwest to 180.7 in Alaska. AI/AN rates were highest in
the Plains regions, where they were similar to NHW
men, but nearly 2-fold or more higher than the rates
for AI/AN men in the remaining regions.
When examined by age group, among those
residing in CHSDA counties, AI/AN men in the 50
years to 64 years and 65 years to 74 years age groups
had lower incidence rates compared with NHW men,
except in the Northern and Southern Plains, in which
the rates were similar (Table 2). For the age group
75 years, AI/AN men in the Northern Plains and
Southern Plains had higher incidence rates than
NHW men (RR of 1.44 [95% CI, 1.19-1.74] and RR of
1.19 [95% CI, 1.03-1.37], respectively).
For AI/AN males, 67.5% of prostate cancers were
diagnosed at the localized stage versus 76.4% for
NHW men (Table 3). Conversely, for AI/AN men,
7.4% of prostate cancers were diagnosed at the dis-
tant stage compared with 4.0% for NHW men; the
differences in incidence rates of late state disease
were not as marked (7.8 vs 6.2) and were mostly
because of a high rate among AI/AN in the Northern
Plains. The distributions of cancers diagnosed at the
regional stage were similar between AI/AN and NHW
men. Finally, the percentage of unstaged cancers was
greater in AI/AN men (16.0%) than in NHW men
(10.0%).
Table 4 presents the prevalence in the 50 states
and the District of Columbia and by region of PSA
testing by demographics and measures of socioeconomic status and access to care. For all regions combined, the prevalence of recent PSA testing was higher
for NHW than for AI/AN men (58.0% and 48.4%,
respectively). AI/AN men in the Southern Plains had
the highest prevalence (54.9%), whereas those in
Alaska had the lowest (28.7%). Overall, increasing age
was associated with a higher prevalence of recent PSA
testing for NHW and AI/AN men. However, among
AI/AN men, there was no consistent relation noted
between age and testing within regions. Having
healthcare coverage; having higher levels of both educational attainment and income; being current with
colorectal cancer screening; being married; reporting
excellent, very good, or good health status; being a
nonsmoker; and being employed or retired were all
14,412
605
4,996
26,750
18,798
10,752
76,313
191
52
322
158
36
150
909
Count
121.8
123.5
109.3
124.5
126.3
101.3
119.4
110.2
62.9
111.9
58.4
48.1
40.8
71.6
Ratea
119.8-123.8
112.8-135.0
106.3-112.4
123.0-126.0
124.5-128.1
99.4-103.3
118.5-120.2
93.8-128.3
45.1-84.7
99.4-125.4
48.9-68.9
32.9-67.4
34.3-48.1
66.7-76.6
95% CI
74.4
66.0
73.4
77.7
78.6
74.1
76.4
64.0
72.4
71.3
68.8
68.0
61.3
67.5
1893
78
535
4232
1732
1444
9914
27
5
34
34
6
32
138
15.6
12.8
11.4
19.1
11.5
13.3
15.1
16.0
4.3
10.7
10.4
7.2
7.6
9.8
Cases, %c Count Ratea
14.9-16.3
9.9-16.3
10.5-12.5
18.5-19.6
10.9-12.0
12.6-14.0
14.8-15.4
9.9-24.0
1.4-10.5
7.4-15.1
6.9-14.8
2.4-16.1
5.1-10.8
8.1-11.7
95% CI
Regional
9.5
6.8
7.7
11.9
7.2
9.7
9.7
9.3
4.9
6.8
12.2
10.2
11.4
9.2
671
25
327
1498
808
418
3747
17
4
24
15
1
24
85
6.0
7.8
7.8
7.2
5.6
4.2
6.2
13.4
7.7
9.8
6.1
1.3
6.9
7.8
Cases, %c Count Ratea
5.6-6.5
4.6-12.0
7.0-8.7
6.8-7.6
5.2-6.0
3.8-4.7
6.0-6.4
7.2-21.9
1.6-19.8
6.1-14.6
3.1-10.4
0.0-7.2
4.3-10.3
6.1-9.7
95% CI
Distant
3.7
4.2
5.2
4.5
3.5
3.1
4.0
7.8
8.9
6.2
7.2
1.8
10.4
7.4
2266
157
827
1908
2506
1746
9410
38
9
59
20
8
33
167
20.2
43.0
20.3
9.5
17.3
17.9
15.6
32.7
12.1
24.6
10.0
14.2
11.3
17.0
Cases, %c Count Ratea
19.4-21.1
35.7-51.2
19.0-21.8
9.1-9.9
16.6-18.0
17.0-18.8
15.3-16.0
22.3-45.7
4.6-24.3
18.4-32.0
5.9-15.6
5.7-27.8
7.7-15.9
14.3-19.9
95% CI
Unstaged
12.3
23.0
13.6
5.9
10.8
13.1
10.0
19.0
13.9
15.7
11.8
20.1
17.0
16.0
19,242
865
6,685
34,388
23,844
14,360
99,384
273
70
439
227
51
239
1,299
Cases, %c Count
163.7
187.2
149.0
160.3
160.6
136.7
156.3
172.2
86.9
157.0
84.9
70.7
66.6
106.1
Ratea
161.3-166.0
173.2-201.8
145.4-152.6
158.6-162.0
158.6-162.7
134.5-139.0
155.3-157.3
150.2-196.2
65.1-113.0
141.9-173.2
73.2-97.7
51.4-94.3
58.0-75.9
100.0-112.4
95% CI
All
100
100
100
100
100
100
100
100
100
100
100
100
100
100
Cases, %c
Source: Cancer registries in the National Program of Cancer Registries of the Centers for Disease Control and Prevention and/or the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute.
CHSDA indicates Contract Health Service Delivery Areas; IHS, Indian Health Service; 95% CI, 95% confidence interval.
a
Rates are per 100,000 persons and are age-adjusted to the 2000 US standard population (19 age groups, Census P25-1130).
b
Based on SEER Summary Stage 2000.
c
Percent stage distribution is age-adjusted to the 2000 US standard population and may not add to 100.0% due to rounding.
Years of data and registries used: 1999 to 2004 (41 states and DC; *indicates states with at least 1 county designated as CHSDA): Alaska,* Alabama,* Arkansas, Arizona,* California,* Colorado,* Connecticut,* District of Columbia, Delaware, Florida,* Georgia, Hawaii, Iowa,* Idaho,* Illinois, Indiana,* Kentucky, Louisiana,* Massachusetts,* Maine,* Michigan,* Minnesota,* Missouri, Montana,* North Carolina,* Nebraska,* New Hampshire, New Jersey, New Mexico,* Nevada,* New York,* Ohio, Oklahoma,* Oregon,* Pennsylvania,* Rhode Island,* Texas,* Utah,* Washington,* Wisconsin,*
West Virginia, and Wyoming*; 1999 and 2002 to 2004: North Dakota*; 2001 to 2004: South Dakota*; 2003 to 2004: Mississippi* and Virginia; 2004: Tennessee.
Non-Hispanic White
Northern Plains
Alaska
Southern Plains
Pacific Coast
East
Southwest
Total CHSDA
American Indian/Alaska Native
Northern Plains
Alaska
Southern Plains
Pacific Coast
East
Southwest
Total CHSDA
IHS Region
Localized
TABLE 3
Prostate Cancer Invasive Incidence Counts, Rates,a and Age-Adjusted Percent Distributions by Stage at Diagnosisb and Indian Health Service Region for American Indians/Alaska Natives
and Non-Hispanic Whites, US, 2001 to 2003, CHSDA Counties
Total
Age group, y
50-54
55-64
65-75
Healthcare coverage
Yes
No
Education
High school graduate
Some college/technical school
College graduate
Annual household income
<$35K
$35K-<$75K
$75K
Unknown
Colorectal cancer screeningj
Yes
No
Marital status
Married
Not married
Health status
Excellent, very good, good
Fair, poor
Smokerk
Current
Nonsmoker (former and never)
Employment
Employed
Unemployed
Homemaker/student/retired
(57.6-58.5)
(40.9-42.8)
(55.9-57.4)
(68.4-69.9)
(59.2-60.2)
(30.1-35.6)
(50.4-51.9)
(57.4-59.3)
(63.4-64.9)
(47.5-49.3)
(59.0-60.5)
(64.8-66.8)
(56.7-59.6)
(71.8-72.9)
(40.2-41.7)
(59.8-60.8)
(48.7-50.6)
(58.3-59.3)
(54.1-56.1)
(45.0-47.4)
(59.9-60.9)
(56.5-58.1)
(44.9-49.6)
(61.8-64.1)
41.8
56.7
69.2
59.7
32.8
51.1
58.4
64.2
48.4
59.8
65.8
58.2
72.3
40.9
60.3
49.6
58.8
55.1
46.2
60.4
57.3
47.3
62.9
(95% CI)
58.0
%h
US NHW
49.3
46.6
51.0
38.4
52.8
48.4
48.7
54.9
38.8
65.6
33.3
45.1
51.2
56.4
54.5
43.6
54.3
54.8
50.1
36.6
43.3
49.9
51.0
48.4
%
(41.3-57.3)
(35.1-58.5)
(37.3-64.6)
(29.6-48.0)
(46.4-59.1)
(42.1-54.8)
(39.8-57.6)
(48.5-61.2)
(31.3-46.8)
(57.4-72.9)
(27.3-39.9)
(37.7-52.7)
(40.7-61.7)
(43.4-68.6)
(41.0-67.3)
(36.4-51.1)
(44.1-64.2)
(43.0-66.2)
(44.4-55.8)
(24.1-51.2)
(34.1-53.1)
(42.1-57.8)
(41.8-60.1)
(43.0-53.7)
(95% CI)
US AI/AN
45.1
53.7
46.4
35.0
51.3
50.9
36.7
50.7
33.6
(31.4-59.5)
(37.7-69.0)
(30.0-63.6)
(22.9-49.4)
(38.9-63.4)
(39.3-62.5)
(24.0-51.6)
(38.1-63.2)
(23.3-45.7)
(64.1-85.2)
(20.4-39.3)
33.5
8.7
52.5
21.9
29.9
32.4
19.9
37.6
13.5
41.8
16.4
(19.4-51.5)
(4.1-17.6)
(30.5-73.6)
(12.1-36.5)
(19.1-43.7)
(21.2-46.0)
(9.1-38.3)
(24.8-52.5)
(7.5-23.3)
55.2
43.9
48.7
48.4
54.8
57.7
44.5
56.7
50.4
65.8
47.7
i
49.8
77.0
47.1
68.5
57.9
i
57.3
55.4
52.7
i
i
76.2
28.9
%
(37.0-72.0)
(28.2-61.0)
(35.9-61.6)
(32.6-64.5)
(43.1-66.0)
(44.6-69.7)
(32.8-56.9)
(44.1-68.5)
(35.2-65.6)
(50.9-78.2)
(34.0-61.8)
(34.9-64.7)
(61.8-87.4)
(32.4-62.4)
(53.0-80.8)
(40.8-73.3)
(45.9-67.9)
(42.9-67.3)
(35.7-69.1)
(44.3-65.0)
(95% CI)
Southern Plainsd
54.9
i
(27.0-58.3)
(9.2-27.5)
(10.7-37.6)
(16.5-39.3)
(22.8-45.4)
(10.2-42.0)
(23.4-48.9)
(19.4-40.2)
(95% CI)
i
(61.1-92.0)
i
21.2
i
i
26.3
i
33.2
i
22.3
35.1
28.7
%
81.0
(24.4-48.8)
(43.7-66.2)
(30.9-55.7)
(31.0-63.8)
(33.4-69.0)
(35.2-54.5)
(21.9-67.3)
(18.7-50.5)
(41.0-69.2)
(28.6-59.3)
(35.5-54.7)
(95% CI)
Alaskac
i
35.7
55.2
42.8
47.0
51.4
44.7
43.2
32.6
55.5
43.3
44.9
%
Northern Plainsb
46.6
i
42.4
26.1
54.9
44.0
53.2
57.1
43.4
62.0
37.8
i
i
52.9
35.2
48.6
41.1
51.7
i
50.4
52.9
45.1
66.6
49.0
%
(20.7-74.5)
(26.9-59.6)
(14.2-43.1)
(38.5-70.3)
(26.6-63.0)
(32.7-72.6)
(40.0-72.7)
(30.7-57.1)
(39.2-80.4)
(24.9-52.7)
(35.0-70.1)
(16.9-59.3)
(29.3-68.3)
(24.3-60.3)
(27.1-75.5)
(36.0-64.8)
(29.6-75.1)
(26.2-65.5)
(47.9-81.2)
(35.2-62.9)
(95% CI)
Pacific Coaste
49.5
54.2
63.9
43.8
54.1
48.4
52.5
57.2
38.0
66.1
29.2
44.0
62.8
46.8
48.8
43.7
61.1
54.9
52.6
31.5
42.9
51.0
51.6
49.7
%
(39.3-59.7)
(40.5-67.3)
(52.3-74.0)
(31.1-57.4)
(45.6-62.3)
(39.8-57.0)
(42.3-62.4)
(48.9-65.0)
(28.7-48.2)
(55.7-75.1)
(21.8-38.0)
(35.1-53.2)
(49.2-74.6)
(31.8-62.4)
(33.5-64.4)
(34.6-53.2)
(48.4-72.5)
(41.6-67.6)
(45.0-60.0)
(18.7-48.0)
(30.6-56.1)
(41.3-60.7)
(39.5-63.5)
(42.9-56.6)
(95% CI)
Eastf
42.3
18.4
48.5
47.0
38.9
41.9
39.3
45.2
32.2
66.4
26.3
i
i
34.3
44.8
32.5
51.8
59.7
41.8
34.0
21.6
43.3
54.0
41.5
%
(27.4-58.6)
(9.0-33.7)
(31.8-65.6)
(continued)
(29.3-65.5)
(30.6-48.0)
(32.5-51.8)
(28.6-51.1)
(35.9-54.9)
(19.8-47.8)
(53.5-77.2)
(17.7-37.0)
(25.8-44.0)
(29.3-61.3)
(22.7-44.2)
(38.4-64.9)
(44.4-73.3)
(33.7-50.4)
(16.2-57.9)
(14.2-31.6)
(30.6-57.0)
(39.4-68.0)
(33.7-49.7)
(95% CI)
Southwestg
TABLE 4
Percentage of American Indian/Alaska Native and Non-Hispanic White Men Aged 50 to 75 Years Who Have Had Prostate-Specific Antigen Testing Within the Previous Year, by Health and Socioeconomic
Indicators and by Indian Health Service Region; Behavioral Risk Factor Surveillance System, 2001, 2002, 2004, and 2006a
NHW indicates non-Hispanic white; AI/AN, American Indians/Alaska Natives 95% CI, 95% confidence interval.
a
Data are from 50 US states and the District of Columbia. Hawaii did not participate in 2004.
b
AI/AN in Illinois, Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming.
c
AI/AN in Alaska.
d
AI/AN in Kansas, Oklahoma, and Texas.
e
AI/AN in California, Idaho, Oregon, Washington, and Hawaii.
f
AI/AN in Alabama, Arkansas, Connecticut, Delaware, Florida, Georgia, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Mississippi, Missouri, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont,
Virginia, West Virginia, and District of Columbia.
g
AI/AN in Arizona, Colorado, Nevada, New Mexico, and Utah.
h
Weighted estimates, age adjusted to 2000 US population.
i
Estimates are not reportable because n<50.
j
Fecal occult blood test within 1year or endoscopy within past 5 years.
k
Smoked at least 100 cigarettes (5 packs) in entire life.
TABLE 4
(continued)
Prostate Cancer Incidence Among AI/AN Men/Henderson et al
1209
associated with increased PSA testing for NHW and
AI/AN men, both nationally and regionally.
DISCUSSION
There are several findings to emphasize from the
current study. First, the prostate cancer incidence
rate for AI/AN men for all regions combined is lower
than for NHW men living in the same counties; however, the rate is higher than reported previously,18-22
although differences in age standardization of rates
may make the comparison difficult. Second, as with
other cancer types,23 AI/AN men demonstrate
marked regional variation in prostate cancer incidence rates in comparison with NHW men. Third,
our data indicate that AI/AN men experience slightly
higher rates and percentages of distant stage disease
than NHW men. Finally, our data also demonstrate
lower rates of PSA testing in AI/AN men than in
NHW men in all regions.
There are several possible explanations for the
lower prostate cancer incidence rates noted among
AI/AN men. First, PSA screening primarily detects
early–stage cancers.24 Many screen-detected early
stage prostate cancers are indolent, non–life-threatening lesions that would not have become clinically
apparent in the absence of screening.25 Therefore, a
lower prevalence of prostate cancer screening will
result in lower incidence rates.26 The BRFSS data
presented herein demonstrated that PSA screening
rates are lower for AI/AN men in every region when
compared with NHW men, often markedly so. Much
of the difference observed in prostate cancer incidence rates between AI/AN and NHW men may be
explained by differences in PSA screening in the
population.
Second, an increasing body of evidence points to
an inverse correlation between type 2 diabetes
mellitus and prostate cancer.27-33 AI/AN men (and
women) have the highest prevalence of type 2 diabetes mellitus of any race/ethnic group in the US.34–38
Diabetes-related hypoinsulinemia and low androgenicity are hypothesized to reduce the risk for prostate
cancer.39 Other hypotheses for this apparent protective effect include decreased testosterone levels, a
common finding in males with type 2 diabetes32,40,41;
the potential beneficial effects of drugs used to treat
diabetes or other conditions42,43; and the possible
role of renal failure.44 The role that diabetes may
play in prostate cancer in AI/AN men is unclear and
is likely to have much less influence on overall rates
than PSA screening.
The current study data also demonstrate a striking
regional variation in AI/AN prostate cancer incidence
1210
CANCER Supplement
September 1, 2008 / Volume 113 / Number 5
rates, exceeding that noted among NHW men. The
rates for AI/AN men living on either the Northern or
Southern Plains approach and even surpass those for
NHW men, and are approximately double the rates
reported for AI/AN men in all other regions. By contrast, the NHW rates reveal at most 35% regional
variation. This marked degree of regional variation in
prostate cancer rates noted among AI/AN men mirrors
that reported for rates of other leading cancer types
among both men and women.3,23,45–47 Although this
variation in prostate cancer incidence modestly tracks
differences in self-reported BRFSS prevalence of PSA
testing among AI/AN men, differences in testing alone
are not likely to explain all the variation. For 1 reason,
our BRFSS data demonstrate an inconsistent correlation between PSA testing prevalence and prostate cancer incidence, including localized stage disease, among
the AI/AN men in our 6 different regions. Beyond the
possible effects of screening differences and the few
obviously tobacco-related cancers—notably lung and
urinary bladder—we really cannot explain this variation noted for multiple cancer types. These data
emphasize the need for etiologic studies designed to
elucidate regional variation in prostate cancer incidence and other cancers that can assist in prioritizing
future cancer control efforts.
Although routine screening with PSA is not
recommended by the US Preventive Services Task
Force nor by most other major health organizations,
it is still widely used by clinicians. Therefore, the differences in PSA testing between AI/AN and NHW
men may reflect similar disparities in health access
as noted for other cancers, such as breast and colorectal, for which screening recommendations are
widely accepted.44,49 Cultural issues may play a role
in the limited use of PSA screening tests in AI/AN
populations. Several studies, involving only AI/AN
females, have examined relations between cultural
beliefs and practices, or ‘‘traditionality,’’ and receipt
of breast and/or cervical cancer screening.50–55
Although the results of these and other studies were
generally mixed, future research regarding the influences of traditionality on receipt of cancer screening
tests (eg, for colorectal cancer) or seeking care when
symptoms develop should include AI/AN men.
The current study has several important strengths.
We used the most current, complete, and accurate
data available regarding prostate cancer incidence and
stage at diagnosis for AI/AN males. Specifically, few
previous studies have reached the broad coverage
achieved in this analysis. In addition, our ability to
conduct data linkages and to restrict our analyses to
CHSDA counties has likely improved the classification
of AI/AN race in participating cancer registries. Finally,
our study includes BRFSS prostate cancer test receipt
data on AI/AN men analyzed by 6 geographic regions.
The current study has several important limitations. First, the analyses presented here for AI/AN
populations are based on residents of CHSDA counties and excluded many AI/AN residents in urban
areas not part of CHSDA counties; therefore, the
findings do not represent all AI/AN populations in
the US or in individual IHS regions, particularly the
East.6 There may be significant differences in cancer
risk–related and screening behaviors between the AI/
AN and NHW men who live in these selected counties and those not living in those counties. Second,
although linkage with IHS patient registration databases improves the race classification for AI/AN
cases, AI/AN persons who are not eligible for IHS
services are not represented in the IHS database.
Third, BRFSS data are limited by being self-reported,
by selection bias related to the sampling strategy and
the relatively low response rate,56 by the small numbers of AI/AN participants, and perhaps most importantly in this case, by the fact that these data were
not limited to CHSDA counties. Finally, we did not
provide comparable prostate cancer mortality data
among AI/AN and NHW men in the CHSDA counties. Other reports have noted that prostate cancer
mortality in AI/AN men in the Plains regions for
time periods similar to our incidence analyses
exceeds that of NHW men.45,57 Future analyses could
determine whether there is an association between
lack of PSA testing, presenting at advanced stage,
and mortality. In addition, linking mortality data
with cancer registry data linked to the IHS patient
registration database could reveal stage-specific mortality rates for AI/AN and NHW men, and be able to
evaluate whether survival differences were related to
access to/receipt of treatment.
In conclusion, AI/AN men have a generally lower
prostate cancer incidence than NHW men and lower
rates of PSA testing. The current study data also
demonstrate marked regional variation in cancer
incidence rates among AI/AN persons. Future
research should include data regarding prostate cancer mortality for AI/AN men to better correlate factors with disease stage, treatment decisions, and
outcomes. In addition, future research among AI/AN
men should also examine the role of diabetes status
and duration as well as other patient factors on prostate cancer screening, incidence, and outcomes.
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